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From: The Rheumatologist, March 2012

First ARHP “Best of the Meeting” Highlights Sleep Research, Osteoporosis Screening, More

by Kathleen Louden

CHICAGO - “The line between ACR and ARHP sessions has totally blurred,” said Donah Zack Crawford, MA, during the presentation, “Highlights from the 2011 ARHP Sessions,” here at the 2011 ACR/ARHP Annual Scientific Meeting held in Chicago in November 2011. Joining Crawford, who is research coordinator with The Arthritis Group in Philadelphia, for what she said was the first ARHP meeting roundup, was Robert R. McLean, DSc, MPH, an epidemiologist at Hebrew SeniorLife’s Institute for Aging Research and assistant professor of medicine at Harvard Medical School, both located in Boston. The presentations they reviewed on the last day of the meeting did have a selection bias, as “these topics are near and dear to our hearts,” said Crawford. [Editor’s note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.]

Sleep Success

In introducing her review of ARHP keynote speaker James B. Maas, PhD, a sleep researcher from Cornell University in Ithaca, N.Y., Crawford said that Dr. Maas coined the term power nap. Dr. Maas presented the keynote address, “Sleep for Success! Everything You Must Know About Sleep But Were Too Tired to Ask.”

Adults who never sleep seven to eight hours a night never get the kinds of brain waves they need, according to research from Dr. Maas’ sleep laboratory. As a result, these people are more likely to be unhealthy and live shorter lives. Lack of sleep increases the risk of hypertension, depression, diabetes, periodontal disease, obesity, and cancer. Teenagers need more sleep than adults—9.25 hours nightly—yet they receive just six hours on average.

Aside from the need to get enough sleep, Dr. Maas recommended good sleep hygiene, such as consuming no caffeine after 2 p.m. and sleeping in complete darkness, said Crawford.

Medical Marijuana

Differing viewpoints made up a session called, “Debate: Joints for Joints: Medical Marijuana Is Useful for Treating Rheumatic Disease.” Debating against medical marijuana was Stuart L. Silverman, MD, of Cedars-Sinai Medical Center in Beverly Hills, Calif. The opposing view came from Arthur F. Kavanaugh, MD, of the University of California, San Diego.

Dr. Silverman’s concerns about medical marijuana include poor product labeling, potential for product contamination, and conflicts between federal and state laws, Crawford said. There also is confusion about dose and delivery systems. “Apparently, the ability of marijuana in a brownie to be equally distributed is somewhat limited,” she recounted from the presentation. Drs. Silverman and Kavanaugh suggested that edible products or vaporizers make better drug delivery systems than smoking.

A patient can have a bad reaction to a contaminant, such as a fungus, in an unauthorized preparation of marijuana. Therefore, the presenters recommended that healthcare providers ask the patient about everything he or she has ingested.

In supporting medical marijuana, Dr. Kavanaugh cited 12,000 years of data, including an ancient Chinese emperor who apparently declared that cannabis can “undo rheumatism.” Good research data show that marijuana reduces pain, said Dr. Kavanaugh.

However, Dr. Silverman stated that medical marijuana “is not ready for prime time.”

Improved Research Tools Needed

“A number of posters and presentations at this meeting showed that the tools we are using to assess our patients are not sufficient,” said Crawford. “Healthcare professionals are saying we don’t have the right tools, and so we are developing our own.”

At least two posters described efforts to obtain patients’ input about which outcomes to measure, using focus groups (abstract 1589) or consumer advisory councils (abstract 1586). In response to these efforts to develop patient-centered research tools, Crawford said, “This is the year of the real patient.”

Researchers must consider whether the data they are collecting in patient questionnaires are correct and meaningful to the patient, she added. For instance, a question asking, “Can you open a milk carton?” is not relevant to a lactose-intolerant arthritic patient, who likely will respond no, even if the patient has the functional ability to open a carton. “We are making clinical decisions for our patients and making changes based on what, I believe, in some cases are faulty data,” Crawford said.

Crawford has observed an important trend, said audience member Elizabeth Harsha-Strong, MPH, of Northwestern University Feinberg School of Medicine in Chicago.

“Some patients have voiced their frustration with questionnaires,” said Harsha-Strong, who administers these forms in her role as a rheumatology research coordinator at Northwestern. “The questions don’t always apply to everyone, and a reply explaining why they answered the way they did won’t be counted.”

Osteoarthritis Database

Dr. McLean called the Osteoarthritis Initiative, a database for knee osteoarthritis research, “an amazing gold mine of data” and “exciting research.”

This databank of approximately 4,700 patients with or at risk of knee osteoarthritis, as well as healthy controls, was described in an ARHP concurrent session by Michael C. Nevitt, MPH, PhD, and John Lynch, PhD, from the epidemiology department of the University of California, San Francisco. Obtained from a multicenter, four-year observational study, the database contains downloadable results of knee images, biomarkers for blood and urine, DNA and RNA, and joint replacement data. The researchers share this dataset, continually expand it, and encourage research collaboration using the data, Dr. McLean said.

Robert R. McLean, DSc, MPH

It turns out that BMI isn’t the greatest tool to assess obesity in everyone.

—Robert R. McLean, DSc, MPH

Alternatives to Body Mass Index

Body mass index (BMI), although the standard measure of obesity, has shown high variability in certain subgroups and tends to underestimate obesity in older adults. Now, the authors of an abstract presented at the ARHP Epidemiology and Public Health I session (abstract 799) conclude that BMI also does not accurately reflect body composition in patients with rheumatoid arthritis (RA).

“It turns out that BMI isn’t the greatest tool to assess obesity in everyone,” Dr. McLean said. “The researchers found a huge discrepancy between BMI and [dual-energy X-ray absorptiometry] DEXA.”

Presenter Patricia P. Katz, PhD, of the University of California, San Francisco, and her colleagues measured body composition in approximately 140 RA-affected patients.

They compared measurements using BMI, waist circumference, and DEXA, which calculated the percentages of muscle mass and fat mass. Among the men, DEXA classified 80% of them as obese, compared with only 29% being classified by BMI; the percentage of women classified as obese was 44% with DEXA vs. 26% with BMI.

Patients with RA had higher trunk fat and lower appendicular muscle mass, which caused Dr. McLean to speculate that waist circumference would be a better measure of obesity in this population. However, he said the investigators found that waist circumference was no better than BMI at assessing body composition in these patients.

“[The presenter] had no explanation for this,” he added. “There is a lot more work to be done looking at measures of body composition in patients with RA.”

Osteoporosis Screening

Two studies presented at the Clinical Practice/Patient Care I session evaluated osteoporosis assessment or screening. Maria Antonelli, MD, of Case Western Reserve University in Cleveland, and her colleagues studied 420 patients with a primary diagnosis of hip fracture not due to cancer or Paget disease (abstract 870).

They found that physicians ordered DEXA after hospital discharge in less than 14% of these patients. “This is evidence that people are not being assessed enough for osteoporosis, even when they know they have a hip fracture,” Dr. McLean said.

Another study showed more hopeful findings, according to Dr. McLean. Presented by Kori A. Dewing, DNP, ARNP, of Virginia Mason Medical Center in Seattle, the study (abstract 869) evaluated the effect of a clinical-decision support system on rates of DEXA bone mineral density screening in 65-year-old women.

The intervention consisted of automatic reminders to doctors in the electronic medical records of patients due for bone mineral density screening.

Screening rates rose from about 80% before system implementation to nearly 100% two years after implementation.

 


Kathleen Louden is a medical writer based in the Chicago area.

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